Professional Documents
Culture Documents
Exam 3
5) Know about the client teaching for alpha and beta agonist and antagonist.
● Agonists (Adrenergic Drugs)
○ Medications are to be used only as prescribed with regard to amount,
timing and spacing of doses
○ Advise patient to immediately report any complaints of chest pain,
palpitations, headaches, or seizures
○ Lung disease patients need to avoid anything that may exacerbate their
respiratory system. Example: Smoking
○ Salmeterol
■ Not to be used for relief of acute symptoms
■ 1 puff twice daily 12 hours apart
■ recheck orders and directions
8) Know everything about digoxin and digoxin toxicity (including dietary , drug
administration, drug interactions, antidote, etc.)
● Digoxin
○ Indications
■ Systolic heart failure
■ Atrial fibrillation
○ Contraindications
■ Known drug allergy
■ second or third degree heart block
■ Atrial fibrillation
■ Ventricular tachycardia or fibrillation
■ heart failure from diastolic dysfunction
■ subaortic stenosis(obstruction of left ventricle below the aortic
valve)
○ Adverse Effects
■ Cardiovascular
● Bradycardia
● Tachycardia
● Hypotension
■ Central Nervous
● Headache
● Fatigue
● Confusion
● Convulsions
■ Eye
● Colored vision (green yellow purple)
● Halo vision
■ Gastrointestinal
● Anorexia
● Nausea
● Vomiting
● Diarrhea
○ Management
■ Between 0.5 to 2 ng/ml
■ Low potassium magnesium levels may increase potential for
digoxin toxicity
■ 20% taking digoxin exhibit toxicity
■ decrease renal function is a common cause of toxicity
○ Predisposing Conditions
■ Use of cardiac pacemaker
● toxicity at lower dosages
■ Hypokalemia
● risk of dysrhythmias increase
● more susceptible to digitalis toxicity
■ Hypercalcemia
● higher risk of sinus bradycardia
● dysrhythmias
● heart block
■ Atrioventricular block
● worsen with increasing levels or digitalis
■ Dysrhythmias
● May occur that did not exist before digitalis
■ Hyperthyroidism, respiratory, or renal disease
● patients with any of these disorders require lower dosages
because they cause delayed renal drug excretion
■ Advanced age
● decreased renal function, diminished drug excretion,
decreased body mass. Lower dose is needed
● polypharmacy also may lead to toxicity
■ Ventricular fibrillation
● ventricular rate may increase with use
○ Step by Step Management to toxicity
■ 1 discontinue administration of drug
■ 2 begin continuous ECG monitoring for cardiac dysrhythmias;
administer any appropriate antidysrhythmic drugs as ordered
■ 3 determine serum digoxin and electrolyte levels
■ 4 administer potassium supplements for hypokalemia if indicated,
as ordered
■ 5 institute supportive therapy for gastrointestinal symptoms
(nausea, vomiting diarrhea)
■ 6 Administer digoxin antidote (digoxin immune fab) if indicated,
as ordered
○ Antidote
■ Route, Onset of Action, Peak, Half Life, Duration of Action
● IV, immediate, immediate, 14-20 hours, days to weeks
■ Digoxin immune Fab
● antibody that recognizes digoxin as an antigen and forms
and antigen antibody complex with the drug
● Only in parental form as 40 mg vial
● All subsequent measurements of digoxin will be elevated
for days to weeks, so you look for signs and symptoms not
digoxin levels
● When to use
○ Hyperkalemia (Serum potassium level higher than 5
mEq/L) in a patient with digoxin toxicity
○ Life threatening cardiac dysrhythmias, sustained
ventricular tachycardia or fibrillation, and severe
sinus bradycardia or heart block unresponsive to
atropine treatment or cardiac pacing
○ life-threatening digoxin overdose: more than 10 mg
in adults, more than 4 mg in children
○ Interactions
■ Important interactions
● Amiodarone, quinidine, and verapamil
○ can increase digoxin levels by 50%
● When large amounts of bran are ingested
○ absorption of oral digoxin may be decreased
● Ginseng
○ Increase Digoxin level
● Hawthorn
○ Potentiate the effects of digoxin
● Licorice
○ may increase the risk of cardiac toxicity due to
potassium loss
● St. John’s Wort
○ may reduce digoxin levels
● Lowering potassium and magnesium
○ predispose to digoxin toxicity
■ Antidysrhythmics, calcium(parental)
● Mechanism-increase cardiac irritability
● Result-Increased digoxin toxicity
■ Cholestyramine, colestipol, sucralfate
● Mechanism-decrease oral absorption
● Result-Reduced therapeutic effect
■ Beta blockers, Calcium channel blockers
● Mechanism-Block Beta1 receptors in the heart
● Result-Enhanced bradycardic effect of digoxin
■ Quinidine
● Mechanism-Block calcium channels in the myocardium
● Result-Enhanced bradycardic and negative inotropic effects
of digoxin
■ Verapamil, amiodarone, dronedarone, cyclosporine, azole
antifungals
● Mechanism-Decrease clearance
● Result-Digoxin levels increased by 50%, digoxin dose
should be reduced by 50%
■
○ Normal therapeutic drug levels
■ between 0.5 and 2 ng/ml
■ >2 ng/ml used for the treatment of atrial fibrillation
○ Route, Onset of action, peak, half life, duration
■ PO, 1-2 hours, 2-8 hours, 35-48 hours, 3-4 days
■ IV, 5-30 minutes, 1-4 hours, 35-48 hours, 3-4 days
● Ointment
○ Use proper dosing paper
○ Apply onto clean dry hairless skin of upper arms or body
○ Avoid below knees and elbows
○ Do not apply ointment with fingers unless glove is worn to avoid contact
with the skin
○ Tongue depressor may be used
● Transdermal forms
○ Apply patches to a clean residue-free hairless area
○ if cardioversion or use of an automated electrical defibrillator is required
■ remove transdermal patch to avoid burning of the skin and damage
to defibrillator paddles
○ New patch
■ remove old patch
■ clean skin
■ dispose of bad patches
■ flush down the toilet
● IV Form
○ Emergencies situations only
○ Close automatic monitoring of blood pressure and pulse
○ Constant ECG monitoring
○ Dangers of IV form
■ lead to sudden and severe
● Hypotension
● cardiovascular collapse
● shock
○ Always check for incompatibilities and proper diluent
○ intravenous solutions through an infusion pump as ordered
● Contraindications
○ known drug allergy
○ Anemia
○ Closed angle glaucoma
○ Hypotension
○ Severe head injury
○ Do not use with Erectile dysfunction drugs
■ Sildenafil-viagra
■ tadalafil-cialis
■ vardenafil-levitra
● Adverse effects
○ Headache-most common and diminishes soon after start of therapy
○ tachycardia
○ postural hypotension
○ reflex tachycardia- vasodilation occurs too rapidly so heart rate increases
■ Baroreceptors falsely sense that there has been a dramatic loss of
blood volume and try to create homeostasis
● Interactions
○ alcohol
○ beta blockers
○ calcium channel blockers
○ phenothiazines
○ erectile dysfunction drugs
● Contraindications
○ Drug allergy
○ Hepatic coma (Metolazone)
○ Anuria
○ Severe Renal Failure
● Adverse effects
○ reduced potassium levels
○ Elevate levels of
■ calcium
■ lipids
■ glucose
■ uric acid
○ Common effects
■ dizziness
■ vertigo
○ Important effects
■ headaches
■ impotence
■ decreased libido
○ Uncommon other effects
■ GI disturbances
■ skin rashes
■ photosensitivity
■ thrombocytopenia
■ pancreatitis
■ cholecystitis
○ Interactions
■ corticosteroids-Additive effect-hypokalemia
■ diazoxide-
■ digitalis-hypokalemia-increased digoxin toxicity
■ oral hypoglycemics
■ Licorice leads to hypokalemia(low levels of potassium)
● Lab Values
○ 0.3-0.5 mcg/kg/min. Max of 10 mcg/kg/min
24) Know everything about heparin (patient effects, patient teaching, lab
values, antidote, drug interactions)
● Drug Effect
○ Antithrombotic drug
■ work to prevent formation of a clot or thrombus
● Indications
○ Risk of blood clots
● Contraindications
○ known drug allergy
● Adverse effects
○ Bleeding
○ Heparin induced thrombocytopenia
● Lab Values
○ aPTT
■ 25-35 sec normal control values
■ 45 70 sec therapeutic values
○ Preg cat C
○ Pediatric
■ IV: 50 units/kg, than 12-25 units/kg/hr, increase by 2-4 units/kg/hr
q6-8h prn
○ Adult
■ Subcut: 5000 units q8-12 hr for prophylaxis
■ IV infusion: 20000-40000 units/day usually given as 80 unit/kg
bolus then 18 units/kg/hr
■ aPTT determines maintenance dosage
● Antidote
○ IV injection of protamine sulfate
■ 1 mg reverses 100 units of heparin
● Drug interactions
○ Enzyme inhibition of metabolism
○ Displacement of the drug from inactive protein-binding sites
○ Decrease in vitamin k Absorption or synthesis by the bacterial flora of the
large intestines
○ Altercation in the platelet count or activity
○ Heparin interactions all lead to increased bleeding risk
■ Aspirin other NSAIDs-Decreased platelet activity
■ Warfarin, heparin, thrombolytics- additive
■ Rifampin- Increased effects
■ herbal therapies
● Garlic
● Ginkgo
● Kava
○ Atorvastatin
■ Lipitor
● lower total cholesterol
● Lower LDL cholesterol level
● Lower triglyceride level
● Raise good cholesterol HDL
● Can be dosed any time of day
● Pregnancy X drug
● 10-80 mg a day
● Usually given at night
○ Simvastatin
■ Zocor
● Lower total cholesterol
● Lower LDL cholesterol
● Lower Triglyceride level
● Raise good cholesterol HDL
● 5-40 mg a day
● Pregnancy X
● 80 mg restriction
● Do not use with list
○ itraconazole
○ ketoconazole
○ posaconazole
○ erythromycin
○ clarithromycin
○ telithromycin
○ HIV protease inhibitors
○ nefazodone
○ femfibrozil
○ cyclosporine
○ danazol
● Special interactions
○ Verapamil and diltiazem
■ do not exceed 10 mg
○ Amiodarone, amlodipine, and ranolazine
■ Do not exceed 20 mg
○ Lovastatin
■ Mevacor
28) Know laboratory values and drug interactions associated with statin
drugs
● Statin drug interactions ^^^^^^^^^^^^^^^^^^^^^
● Lab Values
○ Atorvastatin - Lipitor X
■ 10-80 mg/day
○ Simvastatin - Zocor X
■ 5-40 mg/day
31) Know what solutions are lipids, crystalloids, colloid or blood product
● Lipids or it could mean fat solutions pg 860
○ Two forms
■ Triglycerides
■ Cholesterols
○ Fat solutions
■ Vitamin
● A
● D
● E
● K
● Crystalloids
○ Natural Saline NS-Sodium Chloride
■ 154-NA 154-CL
○ Hypertonic Saline
■ 513-NA 513-CL
○ Lactated Ringer’s Solution
■ 130-Na 190-CL 4-K 3-Ca 28-Lactate
○ D5W 5 % Dextrose in water
■ 1-K
● Colloids most are 154-Na 154-Cl
○ Dextran 70
○ Dextran 40
○ Hetastarch
○ 5% albumin
○ 25% albumin
● Blood Product
○ Cryoprecipitate
○ Fresh Frozen Plasma-FFP
○ Packed red blood cells- PRBC’s
○ Plasma Protein Fraction- PPF
○ Whole Blood